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9 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton,California 95202 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 8 TANK RETROFIT E PIPING REPAIR/RETROFIT 8 UDC REPAIRlRETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Fast Lane Gas Phone# 209-234-4341 <br /> Address L 116 E Roth Rd, Lathrop CA 95330 <br /> TI Cross Street Harlan <br /> Y Owner/Operator Hardeep Gill P <br /> hone707-431-0541 <br /> D Contractor Name Able Maintenance, Inc. <br /> 0 707-545-5522 <br /> N Contractor Address 9 y <br /> T 3224 Regional Parkway, Rosa 95LieClass g A C10 HAZ <br /> R Insurer <br /> A Insurance Company of the Westp# WPL500060302 <br /> C ICC Technician's Name <br /> T DateD ICC Installers NameR Asa Heintz Dale 6!12/2011 <br /> Tank system work area Tank Size Chemicals Stored Current) Dale UST <br /> f+.aT piping amp.91 mk deeew,UVC lrz,arc.) Y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved With conditions LJ Disapproved <br /> L (S Atlachment With Conditions) <br /> A <br /> N Plan Reviewers Name fes„ Date o&0 it <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.' II <br /> Apyll"nrs signature 4zL L b' t u.LQ.Lime Compliance Officer Dat, 6/7/2011 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Marty Weithman TITLE Compliance Officer PHONE (408)213-6038 <br /> ADDRESS 6880'/Quinn Ave.San Jose,95112 <br /> 1' <br /> SIGNATURE �t'(0-LTL Lam- - /'U-(. t"L—Tw DATE 6/7/2011 <br /> EH230038(revised 0220109) <br /> 1 <br />